Episode 125 41 min 40 sec

Approaches to snakebite in Papua New Guinea, and development in Sikkim

Herpetologist David Williams discusses his doctoral research into improving the plight of snakebite sufferers in Papua New Guinea, where snakes constitute a major public health problem. Also, PhD student Thomas Chandy probes community perceptions of the impact of economic development in the remote Himalayan region of Sikkim. With host Eric van Bemmel.

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Approaches to snakebite in Papua New Guinea, and development in Sikkim

VOICEOVER Welcome to Up Close, the research, opinion and analysis podcast from the University of Melbourne, Australia.

ERIC VAN BEMMEL Hello and welcome to Up Close. I’m Eric van Bemmel, thanks for joining us. In this episode of Up Close we hear separately from two researchers whose interests have taken them to a couple of the world’s more out of the way places. Later in the program we’ll be talking to Thomas Chandy about the social implications of development and forestry conservation efforts in the remote Himalayan region of Sikkim. But first joining me remotely from Port Moresby, Papua New Guinea is David Williams a doctoral student in the Department of Pharmacology here at the University of Melbourne, Australia. David is already an experienced herpetologist having worked professionally with crocodiles, snakes and other dangerous reptiles. He also has a keen interest in snakebite epidemiology, venoms and antivenoms. In Papua New Guinea where he makes his home he has done extensive fieldwork often in very remote parts of the country in the area of clinical management of snakebites. Among numerous activities he trains doctors and health workers in how to treat injuries from snakebites and other venomous animals. He was senior editor of the country’s first text book on this topic. Somehow amidst all this he finds time to work on completing his PhD. David Williams, thanks for coming along to Up Close today.

DAVID WILLIAMS It’s a pleasure.

ERIC VAN BEMMEL Now, David, before we get into talking about your specific research can you tell us about the types of snakes to be found in Papua New Guinea?

DAVID WILLIAMS Certainly. Papua New Guinea shares a very common snake fauna with Australia actually. A lot of Australians will be familiar with the death adder snakes, the Taipan snakes, the brown snakes and the black snakes that we have here in Papua New Guinea because they have representatives of the same genuses in Australia. Now for people elsewhere in the world it’s a little bit different. In North America for example they have rattlesnakes which are pit vipers. Australia and New Guinea don’t pit vipers as such we have what are called elapid snakes which are front-fanged, venomous land snakes that have been very successful at occupying all sorts of niches from the foothills of the Kosciuszko mountains all the way through Australia’s very arid deserts. Then here in Papua New Guinea, you know, right into the most dense tropical rainforests. So they are a very successful group of snakes. Papua New Guinea’s biggest snakebite problem is the Papuan Taipan in Southern Papua New Guinea. Throughout Australia there are species of death adder snakes, small snakes that look a little bit like a viper. They are sedentary, they sit on the ground for most of the time hiding and they won’t usually bite anyone unless you actually tread on them or pick them up first. Just like in Australia we have them all the way through Papua New Guinea and we’ve got other species of snakes that are in common as well.

ERIC VAN BEMMEL You have both venomous and non-venomous snakes there?

DAVID WILLIAMS We do, we’ve got our fair share of non-venomous snakes. In fact the majority of snakes here are non-venomous. There are about 120 different varieties, but the deaths from snakebite are all caused by 7 particular species.

ERIC VAN BEMMEL So let’s look at these venomous snakebites particularly. What are the actual effects of being bitten by these types of snakes, you know, physically and medically what happens when we’re bitten?

DAVID WILLIAMS Okay, well the Australian elapid snakes are predominantly neuro-toxic so they have toxins in their venom that target our nervous system and they are very efficient at doing that. But they also have toxins that can affect the ability of our blood to clot which means that people who have been bitten by say a brown snake may bleed quite catastrophically from all sorts of parts of their body, both externally and internally. One of the ways in which a person can die from a brown snake for example is from an intra-cranial haemorrhage into the brain. Because the blood vessels haemorrhage spontaneously into the tissue. Now in Papua New Guinea we have the Taipan snake which has not just extremely powerful neuro-toxins, in fact they are so powerful they actually internalise themselves into the nerve cells and they destroy the nerve cell from the inside out so that the cell no longer exists. That’s one of the reasons why our patients need to be ventilated with machines for sometimes 5 to 10 days after they have been bitten, because their nervous system the nerve endings at the interface with the muscles has been completely destroyed. But they also have toxins that can cause bleeding. So we get patients who present sometimes in as little as half an hour who will be spitting blood from their mouth. They might be bleeding from cuts and scratches that they have or bleeding from other parts of their bodies.

ERIC VAN BEMMEL David, that sounds of course horrific for sufferers of snakebite, but you’ve written that snakebite is a forgotten problem in much of the world. What do you mean by a forgotten problem?

DAVID WILLIAMS Well unfortunately snakebite has slipped under the radar of public health agencies around the world and it’s probably not unlike a lot of other non-infectious diseases. I think people in the general public maybe don’t realise that like many other areas of life public health is very political. You have to be able to lobby politicians and lobby the people who have got the money to fund it. Over the past 50 years or so, we’ve seen that the focus has really been on infectious diseases because these are the diseases that can spread epidemically through populations and affect millions and millions of people. As a result of that diseases that maybe don’t spread, things like snakebite where, you know, the snakebite is one person, that person is not going to infect anybody they are just going to get sick and die have sort of fallen by the wayside in terms of public health importance. We focus very much these days on diseases such as malaria and HIV AIDS and dengue fever and so on. But snakebite seems to have slipped through the cracks as a result there is no funding anywhere internationally for this particular problem. Despite the fact that globally the best estimates that we have at the moment are that it could be somewhere between 85,000 and 125,000 people a year who die from snakebite.

ERIC VAN BEMMEL That’s internationally?

DAVID WILLIAMS That’s internationally, that is right around the world. There could be somewhere between four and five million people a year who are actually bitten by snakes who actually become sick as a consequence of that. Now to put that into a little bit of a context I suppose we can look at the example of dengue fever and globally dengue affects about 50 million people a year. Severe dengue fever, dengue haemorrhagic fever is estimated to kill somewhere between 25,000 and 100,000 people a year. If we compare that to the figures for snakebite we can see that dengue affects ten times more than the five million people affected by snakebite. But when you look at the number of people who are dying, snakebite is on a par. Yet despite the fact that there are enormous resources available to investigate the problem of dengue and to try and find solutions to it there is not a single cent being invested globally to deal with the problem of snakebite.

ERIC VAN BEMMEL Going back to Papua New Guinea for a moment and for listeners outside of our region, we often refer to Papua New Guinea as PNG for short. So how does PNG sort of compare internationally? Is it a big problem there?

DAVID WILLIAMS Well if we look at it in terms of epidemiological incidents and mortality yes it is a big problem. On a population based level there are parts of Papua New Guinea where almost half of a percent of the population are bitten by snakes every year. In terms of fatality we have areas in this country where three times more people die of snakebite than die from malaria, yet again there’s very little put into dealing with the problem. Papua New Guinea does buy antivenoms to treat snakebites. It purchases those from Australia at present because it doesn’t currently have local production of snake antivenoms of its own. The price of antivenom locally is extraordinarily high. It’s almost US$2,000 per vial. Sometimes snakebite patients need more than one vial of antivenom.

ERIC VAN BEMMEL So what is antivenom exactly?

DAVID WILLIAMS Antivenom is basically a preparation of antibodies that have been produced in a horse typically; sometimes it’s done in sheep. But in the case of Papua New Guinea the antibodies are raised in horses that have been immunised with snake venom. So the horses are given very small injections of snake venom, usually in what we call an adjument which delays their absorption into the animal’s body and gives the animal’s immune system a chance to mount a very good response to those particular proteins. So as a result the horse develops antibodies that are able to bind to those proteins and help eliminate it from its body. So we harvest those and they are processed and purified, stabilised and bottled and essentially that’s what becomes an antivenom is a solution of immunoglobulins that have been extracted from horses or sheep and are then used in immunotherapy to treat snakebites.

ERIC VAN BEMMEL How is it actually used with the snakebite victim?

DAVID WILLIAMS Well it has to be given intravenously and the current antivenoms that are in use in Papua New Guinea require cold chain storage so they can only be kept in health centres that have refrigeration and unfortunately not many of our health centres have refrigeration and that limits their access and their availability. It means that patients have to travel very long distances to gain access to antivenom and the longer the delay between the bite and receiving treatment the less likely the patient is to survive.

ERIC VAN BEMMEL If we go back historically in Papua New Guinea, David, how has snakebite been treated?

DAVID WILLIAMS Well from a cultural perspective traditional treatments for snakebite here are highly variable. Most people here in the pre-colonial days would have relied on what we would call witchdoctors, puri‑puri men to come up with traditional treatments. Of course if you’re bitten by a non-venomous snake then these traditional treatments will work just fine. But if you’re bitten by a snake that’s highly venomous then typically the patient would die. In PNG culture that was usually explained away as having been a consequence of somebody else’s witchcraft that somebody had actually used witchcraft to send the snake to bite and kill that particular person. Unfortunately in this society sometimes that led to retribution. People would actually be killed for being witches because somebody in their village had died of a snakebite. Looking at colonial times, at that time when Australian administrators were here we sort of taught the Papua New Guineans a lot of the sorts of first aid that we were using in Australia back in the 1950s and 1960s. For example the use of tourniquets, the use of razor blades to cut open wounds and make them bleed and we know today that these are actually ineffective and in actual fact probably very dangerous types of first aid. If you have a snake venom that causes a patient’s blood to stop clotting, the last thing you want to do is go near them with a razor blade. Papua New Guineans are very good at understanding that they need to do something about snakebites. So even though these techniques were taught to people 50 years ago, even today they are still very commonly practiced because that’s what people remember from the time before independence. We have been doing a lot to try and redress that. In Australia for the last 25 years we have used a much less harmful form of first aid, which is the pressure immobilisation bandaging technique that was developed by the first director my laboratory at the University of Melbourne, Professor Strachan Sutherland in 1979. But it’s only been probably in the last 15years that that technique has started to filter through into Papua New Guinea.

ERIC VAN BEMMEL Now, David, can you tell us about your actual research project? What are you looking at specifically and how are you going about doing that?

DAVID WILLIAMS Sure, my project was to look at the clinical management of snakebite in Papua New Guinea. To look at how snakebite patients are assessed, diagnosed, treated and managed in the hospital environments here and to try and identify particular syndromes of snakebite and venoming that might be linked to particular species. To look at the problems that those syndromes present from a management perspective. So what sort of illnesses do the people have that need to be specifically dealt with? Also to look to at well why do people die of snakebite here. Is it because the venoms of the snakes are so toxic that the people don’t stand a chance? Or is it because there are other problems related maybe to their treatment that result in their deaths? So that’s basically what we’ve been looking at.

ERIC VAN BEMMEL How are you collecting your data?

DAVID WILLIAMS Well we’ve done a lengthy prospective clinical study of snakebite at Port Moresby General Hospital. That is the main teaching hospital based in the capital, Port Moresby. Since 2005 we’ve basically seen all of the snakebite patients who have presented with snakebite at that emergency department. We have collected data from all of those patients. We’ve collected blood samples, urine samples that have been sent for laboratory analysis and for specific laboratory tests so that we could look at different things that are happening. Not just to do with blood coagulation for example but also looking at things like liver function. The effects of snake venom on the human heart. The effects of snake venom on different organ systems in the body so that we can try and have a better understanding of what the venoms of these snakes are actually doing. And to also understand whether or not the treatment that the patients are getting is actually effective and to look at what the post-antivenom complications of snakebite are. So we get a lot of patients who come to the emergency department, they are treated with antivenom but they still don’t get well. Many of them deteriorate quite significantly and may have to be kept alive on a mechanical ventilator for several days. Now that again to Papua New Guinea’s health system is a very expensive exercise and the resources for doing it are very limited. So we want to try and understand why these patients get into that situation and if we can work out ways to try and reduce the number of patients who have these complications.

ERIC VAN BEMMEL Your research has a very wide scope, it sounds like a lot of work?

DAVID WILLIAMS It has been an enormous amount of work.

ERIC VAN BEMMEL I know that you are coming close to completing your thesis and we’ll soon have to call you a Doctor, but can you tell us what you are seeing that’s worth remarking on, you know, even anecdotally? What conclusions have you come up with?

DAVID WILLIAMS Well one of the big things here is that we’ve found that over the last 20 years the proportion of patients who are actually bitten by one particular type of snake the Papuan Taipan in this part of the country that’s serviced by Port Moresby General Hospital has actually increased quite a lot. In the early 1990s Taipans were responsible for about 80 per cent of the snakebites seen at Port Moresby General Hospital. What we have found is that number has now increased to almost 95 per cent and that suggests that the other types of snakes that are found in this area are no longer biting people as often as before which suggests of course that they are no longer here. Certainly the fieldwork that we’ve done suggests that other species of venomous snakes are actually declining in number compared to Taipans. It may well be that is because of deforestation and changes in land use. Some snakes like death adders once you destroy their environment the snake is gone. Whereas Taipans are very adaptable snakes. They adapt very well to areas of human habitation. In fact in areas of farming for example, up here in the agricultural industry oil palm plantations have an enormous problem with Taipans in the southern part of the country because they produce an environment that the snakes are really well adapted to. But looking at the clinical management of snakebites probably the most significant thing that we’ve seen is that for the majority of patients one vial of antivenom has been sufficient to prevent their deterioration if it’s given early enough. But the window of opportunity is only very small. It’s something like four to six hours at the most in order to reduce the percentage of patients who require mechanical ventilation to keep them breathing afterwards. Beyond that period of time, like previous studies have found, a much higher proportion of patients will need that extra medical support for a long period. The other thing that we’ve discovered is that most people who die of snakebite don’t actually die of snakebite. Unfortunately what’s causing the deaths in the hospital here at the moment are what I guess we could term most politely, “medical misadventure.” Patients who may not have received the right treatment at the right time. Patients who might have been incorrectly treated by mistake for some reason. Patients who have complications due to poor nursing, who may not have had their airways suctioned frequently enough and as a result they aspirate fluid into their lungs via the endotracheal tube. That in turn leads to them developing pneumonias and secondary complications of their original problem that contribute to their decline and eventually to their death.

ERIC VAN BEMMEL David, finally, what do you think needs to change in Papua New Guinea specifically and perhaps the world more generally in order to provide better outcomes for snakebite victims?

DAVID WILLIAMS All right, well Papua New Guinea has got two big problems. The first one is that it can’t afford the available antivenom. So it needs another antivenom product that is not going to cost so much money. So we have actually developed a new Taipan antivenom that will cost significantly less than the current product. This new product has performed very well in pre-clinical studies and this year we are looking at putting it through clinical trials here in PNG to see whether or not it meets the necessary safety and clinical efficacy parameters needed to be able to recommend that it be registered for general use. So that is one of the things is we have to make an affordable antivenom available. That is a problem PNG shares with many other parts of the world where antivenoms simply are not available for treating snakebites. A lot of health centres don’t have the ability to refrigerate antivenoms. Therefore we have to look at, well can we stabilise liquid preparations so that they don’t need refrigeration or can we come up with other solutions to the particular storage problems of the developing world. But at the end of the day it doesn’t matter how much antivenom is available if doctors and nurses and other health workers don’t have the necessary skills to be able to correctly diagnose and treat snakebite patients and then manage their after care. So we have to invest also in education and training. We have to give the health workers in these countries the basic skills that they need to be able to manage this particular problem well.

ERIC VAN BEMMEL David, we will have to leave it there. We want to thank you very much for being our guest today on Up Close from faraway Papua New Guinea.

DAVID WILLIAMS No problem, thank you very much.

ERIC VAN BEMMEL David Williams is a PhD student in the Department of Pharmacology at the University of Melbourne. He lives and carries out his research in Papua New Guinea from where he was speaking with us today via Skype. Apologies also to our listeners for the Skype connection which occasionally breaks up and you might have heard some of that in this conversation.

ERIC VAN BEMMEL You are listening to Up Close coming to you from the University of Melbourne, Australia, I’m Eric Van Bemmel. Well we go now from venomous snakes in Papua New Guinea to the social impact of development in Sikkim. Sikkim tucked into the Himalayas alongside Nepal, Tibet and Bhutan is one of India’s tiniest states but is geographically diverse and boasts some of the richest biodiversity in the country. But as in many remote parts of the world there is increasing pressure to exploit resources and build infrastructure as a way to improve living standards for the region’s population. Thomas Chandy is a doctoral student in the Melbourne School of Land and Environment and he’s working to understand how local communities in Sikkim perceive the impact of expanding development projects as well as forest conservation efforts in their midst. Thomas Chandy joins us now in the studio to talk about his research. Welcome, Thomas.

THOMAS CHANDY Thank you, for having me.

ERIC VAN BEMMEL Now, Thomas, before we look at your actual research, can you give us some idea of where Sikkim is and what it looks like?

THOMAS CHANDY Sikkim is a very small state in the North-Eastern part of India. It as you said, tucked in between Bhutan on the east and Nepal in the west. It’s completely mountain country and it has elevations ranging from about 600 feet to 28,000 feet. Mt. Kangchenjunga, which is the third highest mountain of the world is located on the Western border of Sikkim. It has got more than 225 wetlands in the high altitude areas. Most of the streams are glacier fed. They are actively eroding streams. They are very young streams and that explains why the topography is steep and rugged in Sikkim. Sikkim is a very green state. More than 46 per cent of the geographical area of Sikkim is covered by forests and some of the elements of the flora and fauna of that state are highly endemic to Sikkim. It is one of the two hotspots of biodiversity which have been identified by Conservation International in India. The other one is the Western mountain chain bordering the Western coast of India. So Sikkim is very right in flora and fauna. It has more than 4,500 species of flowering plants. It has more than 550 species of orchids which is 10 per cent of the total orchids found in the world. So a state which is hardly a blob on the Indian map and hardly a dot on the world map has 10 per cent of the orchids of the world. You have about 75 per cent of all the butterflies that are found in India are found in Sikkim. More than 150 species of mammal, so it is very rich and varied in its biodiversity.

ERIC VAN BEMMEL What about the people in Sikkim? Your research deals with them quite directly, but can you give us the background on who they are and their history in the region?

THOMAS CHANDY Sikkim was originally inhabited by a couple of tribal groups. One group is the Lepcha, the other is the Suba. They are also called Chongs. There are varying narratives as to how they came into Sikkim. Around the middle of the 17th century, a clan from Tibet called Bhutias, this race was Buddhist and they established this kingdom in Sikkim which lasted for about 300 years until 1975. After the Buddhists came to Sikkim and organised a form of government within that state it was felt necessary to cultivate the valleys which were apparently very fertile. But because the population was sparse at that point of time, the most easily available labour in the nearby areas was the Nepali labour. So the Nepali labour came and they started cultivating the land. They became a part of the population of Sikkim and that explains why they are the biggest ethnic group in Sikkim today. After 1975 and Sikkim became a part of India there was some migration of people from mainland India to Sikkim which was connected to the ongoing development of the place. So you have a multi-ethnic community in Sikkim.

ERIC VAN BEMMEL Multi-lingual as well?

THOMAS CHANDY Multi-lingual yes, very multi-lingual and about 70 per cent of the population is rural. In fact the capital city of Gangtok and some of the major towns of Sikkim grew and became what it is today, post-1975. Before that they were small villages. So all the development took place post 1975.

ERIC VAN BEMMEL But the population today is approximately...?

THOMAS CHANDY Six hundred thousand today approximately. Before the wave of Nepali migrants Sikkim’s main religion was Buddhism and it was a state religion as well. But now Hinduism is the main religion and Buddhism is still quite a prominent religion. Probably one of the states with the highest proportion of people practicing Buddhism is Sikkim in India.

ERIC VAN BEMMEL So in moire recent times there is this pressure to develop, to build infrastructure to aid prosperity and livelihoods of the population. Can you tell us about that in more general terms, what are the activities going on?

THOMAS CHANDY Yes, India has developmental plans which range for five years. The first Five Year Plan that got implemented in Sikkim was the one from 1976 to ’80. Now the planning philosophy for Sikkim as mentioned in the Indian Government’s plan document was there was need for intensive development of Sikkim. The backlog of development needs to be made up because it’s a backward state, that’s what it meant. Since then there have been a lot of infrastructure works basically road development, that’s also a result of the duo-politics of the region, because Sikkim is a border state. So that development of roads and other kinds of infrastructure all the way from 1975 but then over the last 10 years there has been much more work related to infrastructure. Over the last five years there has been a focus on developing the hydroelectricity potential of Sikkim. Sikkim is estimated to have hydroelectricity generation potential of 8,000 megawatts of which about 5,000 megawatts could be tapped immediately. So within Sikkim the power corporation has now leased out projects to private investors to construct 22 hydroelectricity projects within Sikkim.

ERIC VAN BEMMEL That means damming rivers?

THOMAS CHANDY Yes that’s right, so 22 of them within that area of 7,000 square kilometres. These are mostly small to medium sized. But the reason why Sikkim has gone for that is that after a certain period Sikkim would be expected to fund its own plans. It would not receive a lot of assistance from the Government of India. So there is need to earn revenue to fund development and welfare plans for Sikkim. When all the hydroelectricity projects come on stream then the revenue earned would be of the order or more than a thousand crores of rupees which would be around more than US$200 million per year, which is quite a huge amount of revenue. That would be able to finance the development plans.

ERIC VAN BEMMEL How have the forests fared through this process?

THOMAS CHANDY Yes that is the main area of my study, of my project. As I said 46 per cent of the land of Sikkim is covered by forests. Then another 40 per cent of the land is forest land even if they are not covered by forests. Even the alpine meadows and rocky outcrops and things like that are forest land. So if you have some sort of development going on in Sikkim it is bound to impact on forest land. There have been impacts on forest land. Forest lands have got diverted to other land uses. Some forests have had to be removed to put in place development projects. Some of the biodiversity may have been lost. Those things are there and this would have also impacted the communities.

ERIC VAN BEMMEL Is there a forestry industry for example in cutting timber for sale?

THOMAS CHANDY No, no there has never been a forestry industry in Sikkim. It is the Government itself which had been logging areas and using the products from those logged areas for the population. But even that has now stopped. There is no green felling of forest areas in Sikkim for the past ten years. That is one good conservation measure that has been implemented by the Government.

ERIC VAN BEMMEL There is no pressure from outside of Sikkim for...?

THOMAS CHANDY No there is no pressure. There is absolutely no pressure from outside. The only pressure on forests is from development projects. So that is one area that needs to be looked at and how that can be minimised. That is one area that I am looking at through my research project here.

ERIC VAN BEMMEL So these communities that you are interviewing for your research, how do these people go about using the forest for their own purposes?

THOMAS CHANDY Traditionally the people used to depend upon forests for a variety of things. In fact there is one paper which says that probably 75 per cent of the daily use requirements of rural communities is forest based. So what it means is that people are dependant up to an extent of 75 per cent on forests for their livelihood.

ERIC VAN BEMMEL But specifically in what way?

THOMAS CHANDY Yes, so I think the foremost use of forests by rural communities in Sikkim is for medicinal purposes. Sikkim has more than 400 recorded medicinal plants. Before modern medicine came into Sikkim people were using these medicinal plants. In fact there is an institution of local doctors within each of the ethnic communities of Sikkim. They go by different names. They could be called jhakri or bonting. These are the names that are given to local doctors in different communities. These doctors, they would collect medicinal plants from forests and they would be able to treat all kinds of diseases that were prevalent then. Of course people have told me that since development came to Sikkim the kind of diseases that have crept in that people are observing now and experiencing now are different to the ones that they used to have before. Because the ones that they used to have before could be treated by the medicinal plants that were available in the forest. So that was the most important cultural use of forests. Then people used to depend on forests for shelter. Most of the houses were built of timber. Then a lot of food was available from forest areas for example nettles, mushrooms, bamboos. There are about ten varieties of bamboos which have been recorded, the shoots of which were used by people traditionally in Sikkim. Then there were certain kinds of dyes that were extracted from fruits and roots and leaves of plants from the forests of Sikkim which were used for handicrafts and for making wall hangings and prayer flags and things like that. Then if you consider the spiritual aspects of Sikkimese culture, then a lot of forest products were used as incense during worship. Then there were areas within forests which were earmarked as sacred groves and they were not allowed to be touched. They were also the sources of streams which formed the water supply source for villages. So you see there was this inherent forest use based conservation that was playing up during those days. But with the developing of road networks, with modern medicine having reached the villages, people have now stopped using medicinal plants that is one thing. In fact the institution of village doctors itself is threatened now, I don’t think there are many of those left now in Sikkim. With the arrival of markets and with the people changing their vocation from basically agrarian type of livelihood to some other kinds, more modern kinds of occupation I think there has been a change in the use of forests. That is the area that I am looking at, whether that has been good for forest conservation or it hasn’t.